Sunday, February 28, 2010

Reed Abelson's article in today's New York Times should be required reading for all those who want to put the kibosh on the reform process.

Here's the opening of Abelson's excellent piece:

“Hands off my health care,” goes one strain of populist sentiment.

But what if?

Suppose Congress and President Obama fail to overhaul the system now, or just tinker around the edges, or start over, as the Republicans propose — despite the Democrats’ latest and possibly last big push that began last week at a marathon televised forum in Washington.

Then “my health care” stays the same, right?

Far from it, health policy analysts and economists of nearly every ideological persuasion agree. The unrelenting rise in medical costs is likely to wreak havoc within the system and beyond it, and pretty much everyone will be affected, directly or indirectly.

“People think if we do nothing, we will have what we have now,” said Karen Davis, the president of the Commonwealth Fund, a nonprofit health care research group in New York. “In fact, what we will have is a substantial deterioration in what we have.”

In ethics classes we teach that hiding from serious moral issues is a quick route to catastrophe. That's the path we're on. The evil of pushing more and more of our population outside the insurance system, and our cowardly acquiescence to the cancerous growth of health care costs, are like the tectonic plates that eventually cause the kind of massive earthquake we've seen in Haiti and Chile.

One of the attack dog critiques of the Senate and House proposals is that they will lead to rationing, and rationing is wicked. The real issue, of course, is whether we ration in a clinically informed, ethically guided manner, or do it the way we do now, by leaving 50 million outside of the insurance system. Rationing is an ethical requirement for every modern health system. The only question is whether it is done in a fair manner.

The Republicans have done a very effective sabotage job on the administration's efforts. They will probably win some short term political advantage from their "just say no" approach. But the continuing deterioration of our health system and the impact of the health care cost cancer on wages and other societal objectives, will - paradoxically - ultimately lead to much more radical interventions than the current proposals embody.

As costs go up insurers will push harder to control them. But given the degree to which we've demonized the insurance industry, insurers won't be accepted as legitimate sources of cost containment and rationing. I expect that we'll see some of the for profit companies exiting from the business when their margins and stock prices go down. And since for the moment we've rejected the kind of honest thinking about limits that Oregon Governor Kitzhaber introduced 25 years ago, we'll just ratchet down reimbursement, which will scuttle many of our most needed but most vulnerable provider groups.

So here's my prediction. If the Republicans and the Tea Party folks succeed in blocking any meaningful efforts today, we'll see costs and discontent rise steeply. If the Republicans succeed in making Obama a one term president 2012 they'll have a chance to apply their non-ideas. These will fail. The situation will deteriorate further, and after the 2016 election the country will stagger into some form of universal coverage.

As Winston Churchill predicted - "The Americans will always do the right thing... after they've exhausted all the alternatives."

Thursday, February 25, 2010

It's almost two weeks since I did my last blog post. Even when I was in India for a month last year I wrote more than that.

My teaching in the Harvard Medical School medical ethics course is the cause. It's not the time the teaching takes. I'm always busy. Rather, it's that the intellectual and emotional engagement the teaching brings taps the same energy sources that go into the blog.

The course is taught in seminar. My 12 students write 500 word essays each week and get them to me electronically before the seminar. I read the essays on my laptop and respond within the text. The 2/11 topic was informed consent. 2/18 was confidentiality and truth telling. Today was deciding for others.

After WW II Jean Paul-Sartre, Albert Camus, and the other French existentialists encouraged us to be "engagée." The students are decidedly engagée with the topics of the course, and more broadly, with health and health care. That contrasts with what's been most disheartening about the health reform process - the degree to which petty politics and venality have swamped meaningful public engagement with some of the central ethical issues of our era.

I love joining the students as they engage with the ethics of health and health care. There's so much thought, passion, humor, and good will. They evince everything that should characterize health reform but is so pathetically absent.

A month ago I ended a pessimistic post about the prospects for federal reform by invoking the "think globally, act locally mantra." Perhaps the Democrats will be able to squeak a bill past the Republican just-say-no machine. I hope so. But for now it's at the level of states and enterprising employers where the creative action will happen.

And, at the same time, working with future health professionals so that our professions can do a better job of leadership in the future than we've done to date.

Saturday, February 13, 2010

This week a Massachusetts jury found Carolyn Riley guilty of second degree murder for causing the death of her four year old daughter Rebecca by giving her an excessive dose of psychotropic medication.

But when jurors were interviewed after the trial they also expressed outrage at Dr. Kayoko Kifuji, the psychiatrist who prescribed the medication. One juror said Dr. Kifuji "should be sitting in the defendant's chair, too!" And she will in a year or so when the malpractice case brought against her by Rebecca's estate comes to trial.

Rebecca's death reflects two psychiatric tragedies.

First, Dr. Kifuji relied on "data" presented by Rebecca's mother in making her assessment. This is intrinsic to psychiatry. We don't have tests that demonstrate the presence or absence of a condition. We have to rely in significant part on what people tell us. The prosecutors alleged that Carolyn Riley and her husband Michael (who goes on trial next month) deliberately lied to Dr. Kifuji and others to elicit a psychiatric diagnosis that would allow them to collect disability benefits for their children.

We physicians cause harm when we're too skeptical, as when we misdiagnose the pain of a sickle cell crisis as duplicitous opiate-seeking, and when we're too trusting, as the prosecutors allege happened in dealing with the Rileys. Ideally we'd get the balance of trust and skepticism exactly right every time. But that's not possible.

In practice (and in life) I asked myself which mistake I'd rather make, and whenever possible explained my reasoning to the patient. Making a mistake isn't malpractice. Juries, and patients, will forgive an "honest mistake" if we've thought through a situation carefully, have been forthcoming about the rationale for what we're recommending, and treated the patient with respect and compassion.

The question at Dr. Kifuji's malpractice trial shouldn't be whether she made a mistake, but whether she acted with prudence and skill.

The second psychiatric tragedy is intrinsic to the field itself. It's hard for the field, and for individuals, to integrate the biological, psychological, and social components of what we are. We prefer simple explanations to acknowledging complexity and ambiguity.

When I did my training, the pendulum had swung way too far in the psychological direction, and I saw mothers being accused of causing schizophrenia and autism by being cold and rejecting. (I'm happy to be able to say that I never joined that bandwagon.) Now the pendulum is way too biological and we "accuse" children of being biologically off and needing medication when they're restless and bored in school or unhappy at home.

What's happening in psychiatry is a milder version of the polarization we're seeing in our political process. Conservatives blame feckless individuals for their problems. Liberals put the blame on uncaring society. For most issues, both are partly right, partly wrong. But threading our way towards an integrated perspective on complexity seems beyond our national capacity at present.

Friday, February 12, 2010

It only took the jury one hour and a single vote to to acquit nurse Anne Mitchell, against whom a vengeful sheriff and prosecutor had brought an absurd charge of "misuse of official information" for her having blown the whistle on a physician whose care she believed was dangerous. (See here for my post on the charges.)

The jury foreman, Harley D. Tyler, a high school custodian, not a civil rights activist, said that the jury simply saw "nothing wrong" in Ms. Mitchell's actions!

Ms. Mitchell's lawyer will now proceed with the countersuit against the sheriff, the prosecutor, the hospital administrator, and the physician in question. It's worth taking a look at the countersuit filing, which makes what I see as a slam dunk argument. I generally prefer negotiation to litigation, but the attack on a whistleblower is so eggregious that teaching a good solid "lesson" would seem to be a good outcome. Whistleblowing can be abused, but it's a crucial piece of an ethical health care system, and needs to be protected.

Tuesday, February 9, 2010

The most recent issue of the American Journal of Managed care features an interesting article on "Consumer Experience with a Tiered Physician Network" (here), by Anna Sinaiko and Meredith Rosenthal, at Harvard Medical School and School of Public Health, and an accompanying editorial by Peggy O'Kane, President of the National Committee for Quality Assurance (here).

The public thinks of "managed care" as a form of insurance. But on the ground care is managed by physicians and the institutions within which they practice. When insurers actually tried to manage care in the 1990s they succeeded in slowing the cost trend significantly, but they were blown out of the water by provider and patient backlash.

We in the U.S. have a very childlike understanding of health care and a very immature health system. This makes it relevant to consider how children morph into responsible, "well managed" adults.

Children learn through "soft power" - values, incentives, well-timed nudges, and peer influence. Insurance tiering is an effort to influence health care quality and cost by using the same kind of soft power. Here's what Peggy O'Kane says about pharmacy tiering in her editorial:

Tiered pharmacy benefits are one of the few successful cost containment strategies in the past 2 decades. Evidence indicates success on 2 fronts: (1) a positive impact on pharmacy costs and (2) acceptance by members that their choices will affect their own out-of-pocket costs. Against the background of other health plan cost-containment strategies, some of which were subsequently thwarted by public policy and others of which suffered from poor execution and/or lack of provider and patient acceptance, drug tiering stands out as a singular success. It is both ethical and logical to structure choices so that costs are more transparent to consumers and to ask them to bear at least part of the differential cost for a comparable but more expensive product, as long as individuals are not forced to accept lower quality in the favored product. As Americans, we are used to the idea that if we choose a more expensive product, we pay more for it. Third-party payment interrupts the connection between purchasing choices and resultant costs to the individual, but the idea of reference pricing (the third-party payer pays for an equivalent choice at the lowest price, and if the individual chooses a more expensive version, he or she pays the difference) is familiar, and well accepted by customers, in scenarios like auto insurance.

Sinaiko and Rosenthal surveyed consumers about their responses to tiered networks that were part of the insurance offered by the Massachusetts Group Insurance Commission (GIC), a state agency that provides health insurance and other benefits to 300,000 state employees and family members. Here's what GIC Executive Director Dolores Mitchell says about tiering in the 2009 Annual Report:

Throughout Fiscal Year 2009, the GIC was in the forefront of efforts to frame the debate on how best to control rising health care costs while improving quality. The GIC’s Clinical Performance Improvement (CPI) Initiative continued its ground-breaking work -- analyzing differences in provider efficiency and quality and giving members incentives through lower copays to see better performing providers. The program has helped spark debate in the health care community about the role providers must play in improving quality and cutting the overuse of resources...the GIC’s Clinical Performance Improvement (CPI) Initiative, now in its fifth year, seeks to:

Under the CPI Initiative, the GIC requires our health plans to provide de-identified claims for their entire book of business to our consultants for aggregation and analysis for each provider’s efficiency and quality relative to his or her peers. After this process, the results of the analysis are given to the health plans who then use the information to develop tiered networks in which members are given modest co-pay incentives to use better performing doctors.

In general, approximately 20% of physicians earned a Tier 1 rating, 65% were in Tier 2 and 15% were in Tier 3.

(Tiering is largely limited to the specialties for whom enough claims data is available, but some plans tier primary care physicians as well.)

Sinaiko and Rosenthal's basic finding was that as of 2007, only half of the employees enrolled in tiered networks realized that tiering was part of their plan. Of concern for those who believe in tiering, 58% didn't trust the tiers to tell them which doctors were best. Only 20% would trust either their employer or their health plan to establish the tiers. The highest level of trust for tiering (49%) would go to a medical society.

There was, however, some evidence for use of tiering in ways that the GIC hoped to see. Of the 20% who knew the tier rating of at least one of their doctors, 50% learned about the tier rating before their first visit and reported that the information was important to their choice of who to see.

Patients may not yet be paying much attention to tiering, but physicians are intensely aware of the ratings they receive. The Massachusetts Medical Society has brought a suit against the GIC tiering program (here) - a court hearing on the merits of the suit is pending.

Most physicians who have thought deeply about how best to manage quality and cost believe we need to establish a budget for health care, with physicians responsible for providing the best possible care within that budget. This is the vision Grumbach and Bodenheimer argued for 20 years ago in their seminal Health Affairs article "Reins or Fences: A Physician's View of Cost Containment." In our current political climate, however, budgets are seen as part of "socialized medicine" and "government intrusion." Tiering of providers is a second best approach to the effort to improve value (quality per unit of cost) in health care. It's an ethically solid concept for which the key challenge is getting the tiering system right. The Sinaiko/Rosenthal study shows that we're just putting our national toe into the tiering waters. But it's an experiment well worth working on!

Sunday, February 7, 2010

Tomorrow nurse Anne Mitchell, formerly compliance officer at Winkler County Memorial Hospital in West Texas, will go on trial for "misuse of official information" in reporting concerns about Dr. Rolando Arafiles to the Texas Medical Board.

The story, reported today in the New York Times, is fascinating and important on several counts. Whatever the truth of her allegations, the charge being brought against her itself appears to be tainted by conflict of interest:

"When the medical board notified Dr. Arafiles of the anonymous complaint, he protested to his friend, the Winkler County sheriff, that he was being harassed. The sheriff, an admiring patient who credits the doctor with saving him after a heart attack, obtained a search warrant to seize the two nurses’ work computers and found the letter...

Sheriff Roberts, who has held the post for 18 years, said the state would show that the complaint had been filed in vengeance. 'If it’s made to destroy somebody’s reputation or forcing them to leave town,' he said, 'then I don’t believe it is good faith.'

Ms. Mitchell had reported quality of care concerns about Dr. Arafiles to the Medical Board, including a failed skin graft performed in the emergency room, without surgical privileges, and an unusual intervention - suturing a rubber tip to a patient's crushed finger for protection, for which he was later chastised.

From my reading of the New York Times article I interpret the story this way: Ms. Mitchell and her colleague Vickilyn Galle, the quality improvement officer, against whom charges have been dropped, were concerned about what they saw as a pattern of unsafe practice by Dr. Arafiles. They brought their concerns to the hospital administrator and medical staff but felt that the response was too slow. This led them to write, anonymously, to the Texas Medical Board. The administrator did not defend Dr. Arafiles, but complained that the nurses had acted in bad faith by going behind his back by to the Medical Board. Although between them the two nurses had worked at the hospital for 47 years, held responsible positions, and had never received a negative review, he fired them.

While it could be argued that the nurses should have informed the hospital of what they were intending to do, to give the hospital a final chance to deal with the concerns internally, any health professional with good faith concerns about (a) potentially serious lapses in quality of care that (b) the responsible local authorities are not addressing is (c) ethically obligated to go outside of the organization to (d) bring attention to bear on the situation.

This case does not belong in court. I was happy to learn that counsel for the nurses has brought a countersuit alleging vindictive prosecution and denial of the nurses’ First Amendment rights against the sheriff, the prosecutor, the hospital administrator, and the physician in question.

The filing of the countersuit makes fascinating reading. To me it reads like a slam dunk argument. Unless important new facts emerge that put the situation into a dramatically different light I hope the countersuit continues. It could send a powerful message to all those who contemplate attacking the whistleblowing messenger. The assault initiated by Dr. Arafiles and Sheriff Walker, the prosecutor's decision to initiate a criminal action against nurse Mitchell, and the hospital's decision to fire them, will come back to haunt them.

(For a seminal article about the ethics of medical professionalism by Matt Wynia and colleagues, see here)